Do you have a nagging tennis elbow? Just get it zapped with an ultrasound needle. Rotator cuff won’t heal? Perhaps try an injection of your own blood platelets or stem cells and get the tendon to regenerate.
Of course, it’s not that easy. Or is it? As often happens in modern medicine, what might sound like science fiction is here today. Seemingly miraculous regenerative procedures are now readily available in the orthopaedic world, a potential game changer for mending the ailments listed above and more.
Orthopaedic doctors caution these techniques are still being refined as to exactly what works and on what type of damaged tissue, but they report many success stories. Some experts say the future is now when it comes to these procedures.
“People don’t want pills, they want cures. They don’t want a damaged tendon or ligament just covered up with steroids or cortisone,” says John Bartsch, MD, a certified specialist in physical medicine and rehabilitation at Beacon Orthopaedics. “These types of (regenerative) procedures offer hope in that direction.”
Bartsch is part of a new and evolving sub-specialty known as interventional orthopaedics. It focuses on non-operative, minimally invasive management of chronic issues. It is growing field, thanks to new technologies in diagnostics and imaging, along with breakthroughs in platelet and stem cell research.
Traditionally the orthopaedic specialist treats a patient with ligament and tendon damage on a conservative continuum of care that progresses from such techniques as diet, ice, ibuprofen and physical therapy to anti-inflammatory drugs and steroids, with surgery as the last resort. Bartsch says many patients are stuck in a “no man’s land” where treatments aren’t working and surgery seems too extreme. That’s where interventional orthopaedics can be of service, offering various regenerative technologies that might be effective.
“These are the people I talk to about interventional options,” Bartsch says. “We’d love to get away from cortisone and steroids, because we are finding more and more problems with that treatment.”
Bartsch says breakthroughs in imaging have made it possible to explore these options. “We can now see exactly where tendons and ligaments are broken down. Advanced imaging has already helped guide the surgeon; now it is getting so good we can see a diseased area without opening the skin. New devices allow us to target injections into the diseased part of a tendon and avoid injecting something into the healthy part.
Several injection treatments are available. First, ultrasound waves can be used.
Although “zap” is not a technical word doctors like to use, Bartsch says, in a sense that’s what happens in a procedure where a needle directs an ultrasound wave at damaged tissue. “The energy from the ultrasound is able to break down the diseased part of the tendon, leave the healthy part, and sort of washes that area as it is doing it.”
He compares it to a sonic toothbrush breaking down plaque around gums, or, for that matter, the opera singer breaking the glass. Even more exciting is the use of platelet-rich plasma (PRP). A
PRP solution is prepared by drawing a small amount of the patient’s blood and putting it in a centrifuge to separate platelets from the other blood cells. Platelets are known for their growth proteins that are important in the body’s healing process. The PRP is then injected into the damaged area with imaging directing it to the tendons that need to be repaired.
A similar procedure is used with a person’s own stem cells, although the extraction process can be more complicated.
In each case, the patient’s body is used to heal tissue. “PRP acts as a signaling component injected into worn down tendons and tells a healing process to begin, almost a rebooting of the system,” Bartsch says. “In our bodies, platelet cells are the first to arrive at an injury, such as when you get a cut. They send signals to cells all over the area to start a cascade of healing.
“PRP has been changing everything in the way we look at nonoperative treatment.”
Physicians have reported the best results with PRP in patients suffering from chronic tendon and ligament injuries such as tennis elbow, runners knee and plantar fasciitis.
Bartsch acknowledges the jury is still out on how effective the procedure can be. Technically, the treatment is regarded as experimental, but it is extremely safe since patients are using their own blood-based fluids. There are no foreign drugs introduced.
The profession is still learning when it comes to getting the PRP recipe just right, Bartsch says. “We are fine tuning the amount of platelet concentration, and how many white versus red blood cells to put in the mix, and learning what type of injection works in tendons.
Yes, there have been mixed reviews, but we are honing this, and clarifying and we are getting better. We are getting it nailed down.”
Doctors and patients around the country have reported spectacular results from such injections. For example, Bartsch says he recently treated a woman with bursitis in her hip who was not getting better after multiple cortisone shots. “I gave her one PRP and she got 90 percent better in three weeks. So absolutely we are seeing benefits.” Bartsch says it is an especially viable option for a younger person who has a tendon or joint injury but doesn’t want to commit to replacement surgery at a young age.
No major study has been done to confirm the body of positive anecdotal evidence. That’s one reason such techniques remain experimental and many insurance companies do not cover the cost of such procedures. But Bartsch believes it is only matter of time before that begins to change as PRP and similar procedures become more commonplace.
“It’s very safe and a game changer, because who knows if we can ever mimic in the lab what the body’s own cells can do,” he says. “Cardiologists are doing amazing things with healing scarred heart tissue in heart attack patients by injecting new cells. We can do a similar thing. This is the direction of orthopaedics and general medicine for at least the next 15 years.”
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